Analysis of the NEJM Catalyst Insights Council Survey on Chronic Care Models. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.

Advisor Analysis

By Amy Compton-Phillips and Eric Weil

Many health care organizations are reasonably effective in treating chronic diseases, but they are limited from doing better by fee-for-service payment, which remains the predominant payment model in the United States. The latest NEJM Catalyst Insights Council report serves as a snapshot in time, showing the intent of health care providers to be proactive in treating chronic disease, but limitations in their ability to address population health.

Amy Compton-Phillips, MD, Executive Vice President and Chief Clinical Officer for Providence St. Joseph Health and leader for NEJM Catalyst’s Care Redesign theme, says many health systems are in limbo because of payment models. “Although a very large portion of the health care spend involves managing chronic conditions, many health systems can’t be more proactive because we get paid to take care of people when they are sick. We aren’t paid to review populations of patients,” she says, emphasizing that “the business model influences how much you can spend on proactive versus reactive care.”

Many health care organizations are reasonably effective in treating chronic diseases, but they are limited from doing better by fee-for-service payment.”

The top three challenges for chronic disease management, as listed by respondents, clearly demonstrate this constraint. Lack of time for clinicians to see patients with chronic conditions (selected by 44% of respondents), insufficient care coordination to ensure best outcomes (39%), and lack of patient resources for self-management (27%) are largely resolved in value-based care and capitated models, according to Compton-Phillips.

“It’s important to understand where we are today to understand where to channel resources going forward,” says Eric Weil, MD, Director of Population Health for the Department of Medicine and Associate Chief, section of Primary Care at Beth Israel Deaconess Medical Center. “The survey helps highlight the gap-to-goal in terms of utilization and effectiveness.”

According to our survey, 80% of Council members — a qualified group of U.S. executives, clinical leaders, and clinicians who are directly involved in health care delivery — consider their organization’s approach to caring for patients with chronic conditions to be proactive.

“There are many opportunities to be proactivefor any illness. It could mean that every patient who’s screened for diabetes and determined to have early illness receives aggressive education,” Weil says. “It could mean dedicating staff to ensure that diabetes-diagnosed patients schedule and attend necessary appointments. And it could mean that patients with uncontrolled sugar receive an automatic referral to an endocrinologist.”

It is important to see that there is at least consistency in sentiment between leadership and frontline clinicians.”

A heartening aspect of the survey results, in his view, is that executives and clinicians are close in their assessment of how proactive their organizations are: 84% of executives say their organizations are extremely proactive, very proactive, or proactive in caring for chronic conditions compared to 76% of clinicians. “It is important to see that there is at least consistency in sentiment between leadership and frontline clinicians.”

Weil says organizations with larger revenue and infrastructure can be proactive in treating chronic diseases because “they not only have more comprehensive programming, but they are also more willing to take on more risk to pilot new programs. Systems that have fewer resources or are earlier in their journey toward value-based care don’t have the economies of scale or depth of resources to be proactive.”

Respondents were highly optimistic about the impact that primary care and specialty care can have on chronic disease management, with primary care considered more impactful compared to specialty care. Weil says it comes down to the medical condition. Some people, like heart failurepatients, frequently require specialty care, while diabetes, in its early stages, is better suited to primary care, where non-physicians can closely manage the population at a lower cost.

“The vast majority of diabetics can be managed with routine chronic disease management, outreach, education, and follow-up. The rest need more, such as titrating of medications by a pharmacist, close monitoring by a nurse practitioner, or eventually referral to a diabetologist,” he says. “It is important to make sure that the right level or intervention is targeted to the appropriate patient.”

Council members are less optimistic about the current use and effectiveness of tools such as telehealth/telemonitoring and remote monitoring (wearables) that should help them handle patient populations with chronic disease in a more efficient manner and, ultimately, improve outcomes. Nearly half of respondents (48%) say telehealth/telemonitoring programs are not very effective or are ineffective, and 53% respond similarly about remote monitoring devices.

The health care industry has to temper its need for rapid return on investment and follow the guiding principle of ‘doing positive things for patients, even if sometimes that positive impact may not be realized in the short term.’”

Compton-Phillips says technology improvements such as telehealth and remote monitoring devices can be “a comfort to patients because they know others are watching and they know their own outcomes.” Yet she doesn’t see these modes of care taking off until the reimbursement system is changed. “Right now, there isn’t much value seen in telehealth and remote monitoring devices by executives, clinical leaders, and clinicians because we don’t have the right [payment] model,” she says. For example, she says physicians are paid to see patients in-office, not via telehealth, so there is no benefit to them to utilize those tools. “The value would come if an office could be reimbursed for telehealth visits with nurse practitioners for sore throats and RX refills. A physician is not going to pay a team to follow up with patients if she is not getting paid,” she says. Furthermore, “giving physicians more non-reimbursable work is just increasing the likelihood of burnout.”

Weil suggests the health care industry has to temper its need for rapid return on investment and follow the guiding principle of “doing positive things for patients, even if sometimes that positive impact may not be realized in the short term.” Some diagnoses, such as depression, may or may not register improvements for years, yet “You have to be comfortable with making an upfront investment and assessing over extended periods to see improved clinical outcomes as well as improvement in total cost of care.”

VERBATIM COMMENTS FROM SURVEY RESPONDENTS

What is the most effective intervention/program you know of for improving care for patients with chronic diseases? Why has it been successful?

“Addressing the social determinants of disease. Gets to the root cause of issues; keeps people in their communities.”— Clinical leader at a large nonprofit health system in the Midwest

“Care management team intervention; nurses, SWs and community health workers. It’s an integrated and coordinated approach.”— Executive at a midsized nonprofit physician organization in the Northeast

“Checking blood pressures at home twice a day for hypertension. Doing finger stick three times per day to check blood sugars in type ll diabetes. Patients are more mindful of their fluid and sodium intake during any given day and report to their primary care doc if BP not under reasonable control. Patients watch their carbohydrate intake more carefully when they are monitoring their blood sugars.”— Clinician at a small for-profit physician organization in the West

“Easy access and non-stigmatized mental health care. Offer on-site / close by, flexible hours and no costs for employees.”— Clinician at a small nonprofit teaching hospital in the Northeast

“Medicare’s Chronic Care Management Program. The additional revenue has attracted physician attention and provided seed funding for program development.”— Vice President at a midsized nonprofit health system in the West

Download the full report for additional verbatim comments from Insights Council members.

Charts and Commentary

by NEJM Catalyst

We surveyed members of the NEJM Catalyst Insights Council — who comprise health care executives, clinical leaders, and clinicians — about chronic care models. The survey explores the proactiveness of organizations’ approaches to providing care to patients with chronic conditions, the effectiveness of organizations’ chronic disease management programs, the impact of organizations’ primary and specialty care on chronic disease management, chronic disease management care challenges, the use and effectiveness of telehealth/ telemonitoring tools and remote monitoring devices in chronic disease management, and the availability and effectiveness of wellness incentive programs. Completed surveys from 587 respondents are included in the analysis.

A strong majority of the survey respondents (80%) indicate their organization has a proactive approach to providing care to patients with chronic conditions.

More than two-thirds of Insights Council members rate all aspects of their organizations’ chronic disease management programs as effective. A higher incidence of executives (82%) than clinicians (74%) rate the quality of their organization’s chronic disease program as effective.

Eric Weil, MD

Discuss

Your email address will not be published. Required fields are marked *

Comment

Name *

Email *

Save my name and email in this browser for the next time I comment.

Your email address will not be published. Required fields are marked *

Note: This is a moderated forum and all comments are reviewed before posting. By clicking on the "Post Comment" button below, you agree to abide by the NEJM Catalyst Terms of Use. We reserve the right to not post every comment; including those that are submitted anonymously or that are potentially illegal, vulgar, libelous, or commercial in nature.

N. BERTHA

This is largely nonsense. The idea of complete management is a false flag. The example here is the obesity epidemic. There is a DEMONSTRATED benefit to chronic disease from bariatric surgery. Diabetes, heart disease in all of its forms, cancer risk reduction, musculoskeletal issues resolution, its all there. And its all ignored, even at the ivory tower integrated centers. I don't believe that fee for service vs value based care will make the least difference here. It is the 800 lb gorilla which unveils the entire process as a scam to continue the status quo as the $ involved are significant above the physician level.

September 11, 2019 at 9:14 am

Reply

Name *

Email *

Comment *

Save my name and email in this browser for the next time I comment.

Your email address will not be published. Required fields are marked *

Note: This is a moderated forum and all comments are reviewed before posting. By clicking on the "Post Comment" button below, you agree to abide by the NEJM Catalyst Terms of Use. We reserve the right to not post every comment; including those that are submitted anonymously or that are potentially illegal, vulgar, libelous, or commercial in nature.

Allegheny General Hospital created a comprehensive solution for patients with chronic obstructive pulmonary disease (COPD) that led to improved clinical outcomes, reduced hospital admissions and readmissions, and a resultant decrease in the total cost of care.

For big tech companies like Amazon, Apple, and Google, the health care sector looks ripe for disruption. Two executives working in different parts of the health care ecosystem discuss what this means for patients and doctors, including the positives and unintended consequences.

Some promising innovation is taking place among organizations that rate hospital performance, but major systemic change is needed in the field to ensure access to meaningful comparisons through better data and relevant metrics, and to establish integrated oversight through robust audits and peer review.

Co-founders of an integrative outpatient treatment center for mental health and addiction discuss the problematic lack of continuity of care between inpatient and outpatient and physical and mental health services.